Burns pt 1

Question 1

What are the 2 major causes of death in burn patients?

Answer 1

Multiple organ failure and infection

Question 2

How are burn injuries classified?

Answer 2

Burn injuries, regardless of their etiology, are classified according to the depth and extent of skin and tissue destruction, as well as the Total Burn Surface Area (TBSA) involved.

Question 3

What are First Degree Burns?

Answer 3

First-degree (superficial) burns are limited to the epidermis, the outermost layer of skin. Think sunburn.

Question 4

What are Second Degree Burns?

Answer 4

Second-degree burns, also known as deep and superficial partial-thickness burns, extend to the dermis.

Question 5

What are Third Degree Burns?

Answer 5

Third-degree burns, or full-thickness burns, extend to the subcutaneous tissue lying below the dermis. The entire skin thickness is destroyed with third-degree burns.

Question 6

What are Fourth Degree Burns?

Answer 6

A fourth-degree burn classification is used by some to describe structures burned below the dermis, such as muscle, fascia, and bone. (more seen with electrical injuries)

Question 7

What does the Rule of Nines calculate?

Answer 7

The severity based on the amount of surface area covered in second and third-degree burns.

Question 8

What is the percentage associated with the arms, head, legs, and torso?

Answer 8

Arms - 9%
Head - 10%
Legs - 18%
Torso - 36%

Question 9

What is a Major Burn?

Answer 9

-A second-degree burn involving more than 10% of the TBSA in adults or 20% at extremes of age
-A third-degree burn involving more than 10% of the TBSA in adults
-Any electrical burn
-A burn complicated by smoke inhalation.

Question 10

What are the 4 types of burn injuries?

Answer 10

-Thermal
-Electrical
-Chemical
-Inhalation

Question 11

Describe Thermal Burns

Answer 11

(43% flame, 34% scald, 9% contact, 7% other)
-Commonly occur in/around the home
-Scald injuries predominantly children

Question 12

Describe electrical burns

Answer 12

-Extent of burn depends on amount of thermal energy conducted through the skin
-10-46% cardiac arrhythmias and myocardial damage
-Severe damage to bones, blood vessels, muscle and nerves
-Myoglobinemia increased risk of renal failure

Question 13

Describe Chemical burns

Answer 13

-Commonly occur in a laboratory/industrial setting
-Skin disruption continues until irritant is removed/neutralized
-Initial Tx: application of copious amount of water or NS irrigation

Question 14

Describe Inhalation burns

Answer 14

-Often accompany a thermal burn, airway damage can vary
-Classification based on anatomic location:
Upper-airway, lower-airway, and metabolic asphyxiation. All 3 types may coexist in the burn patient.

Question 15

What are the warning signs of respiratory injury?

Answer 15

-hoarseness
-sore throat
-dysphagia
-hemoptysis
-tachypnea
-the use of accessory muscles
-wheezing
-carbonaceous sputum
-elevated carbon monoxide levels
-Observance of soot around nose/mouth

Question 16

What is the biphasic organ response to burn injury?

Answer 16

The treatment of the burn patient will evolve as they progress through the early resuscitative phase to the later hypermetabolic state.
-Early changes and later changes differ based on organ system

Question 17

What are the early changes associated with organ response to burn injury?

Answer 17

-CV: Shock
-U: Oliguria
-GI: Ileus
-MSK: Hypoperfusion
-Pulm: Hypoventilation
-Endo: Catabolism
-Immuno: Inflammation (SIRS)
-CNS: Agitation

Question 18

What are the Late changes associated with organ response to burn injury?

Answer 18

-CV: Hyperdynamic
-U: Diuresis
-GI: Hypermotility
-MSK: Hyperperfusion
-Pulm: Hyperventilation
-Endo: Anabolism
-Immuno: Suppression
-CNS: Obtundation

Question 19

What are the 3 phases of management of the burn patient?

Answer 19

-Resuscitative Phase
-Burn Management: Debridement & Grafting
-Reconstructive Phase

Question 20

What is the goal of burn therapy?

Answer 20

The goal of burn therapy is to rapidly restore skin integrity.

Question 21

What are the pulmonary changes associated with burns?

Answer 21

-Decreased FRC and Chest wall compliance if chest wall burned
-Fluid shifts, interstitial edema, release of inflammatory mediators = pulmonary edema
-Significant a-A Gradient increases (Minute Ventilation increases to 40 L/min from normal 6 L/min)
-CXR normal in early phase progressing to pulmonary edema

Question 22

Why is the burned patient at risk for Pulmonary Edema?

Answer 22

-Impaired vascular/capillary permeability combined with fluid resuscitation
-Mechanical ventilation often required especially with concomitant inhalation injury

Question 23

What is important to know regarding ALI & ARDS and the burned patient?

Answer 23

-Acute onset of impaired oxygen exchange; partial pressure of arterial oxygen/fraction of inspired oxygen (Pa o 2 /Fi o 2) ratio of less than 300.
-Increased risk M&M due to respiratory failure, hypoxia, multiorgan failure, and pneumonia

Question 24

What are ventilation strategies to use in the burned patient?

Answer 24

-Low-volume lung protective ventilation reduces overinflation and barotrauma
-Use ideal body weight
-PEEP
-Modest permissive hypercapnia
-Nonconventional and high-frequency oscillatory modes of ventilation

Question 25

What is the gold standard for airway eval in the burned patient?

Answer 25

Fiberoptic bronchoscope is the gold standard!

Question 26

What is the treatment of upper airway injury?

Answer 26

Early endotracheal intubation secondary to glottic/facial edema worsening with resuscitation.

Question 27

Which patients are at risk for airway damage?

Answer 27

Involving a fire that occurred in a closed space or the development of unconsciousness or stupor that prevented the patient from protecting their airway

Question 28

How does injury differ above the oropharynx vs below the vocal cords?

Answer 28

Above the oropharynx: thermal injury produces inflammation that can occlude airway.

Below VC: damage is due to soot/chemicals (heat dissipates by this point).

Question 29

Why do you avoid the use of Succinylcholine > 24 hours after burn injury?

Answer 29

-Ach receptor up-regulation occurs after burn injury
-Succ releases K+ = possible cardiac arrest

Question 30

How does Carbon Monoxide cause its effects?

Answer 30

Binds to Hgb with 200 times greater affinity than O2.
-50-60% fire victims die from CO poisoning

Question 31

What are the S/Sx of Carbon Monoxide poisoning?

Answer 31

-Metabolic acidosis
-Oxy-Hgb dissociation curve LEFT
-Dec O2 content on ABG
-Falsely elevated SpO2 reading (pulse ox doesn’t detect CO)

Question 32

How do you diagnose CO poisoning?

Answer 32

COHgb levels using a laboratory co-oximeter

Question 33

How do you treat CO poisoning?

Answer 33

-100% O2 until COHgb level < 5% or for 6 hours
-Hyperbaric O2 therapy debatable

Question 34

How does Hydrogen Cyanide poisoning occur?

Answer 34

HCN poisoning is produced by the combustion of plastics, foam, paints, wool, and silk.
-Binds terminal cytochrome on the electron transport chain blocking the intracellular use of O2

Question 35

What are the S/Sx of Hydrogen Cyanide poisoning?

Answer 35

-Hypoxia, lactic acidosis, elevated mixed venous saturation
-loss of consciousness, dilated pupils, seizures, hypotension, and tachypnea followed by apnea

Question 36

What is the half-life of Hydrogen Cyanide?

Answer 36

1 hour (!)

Question 37

What is the treatment for Hydrogen cyanide poisoning?

Answer 37

-Hydroxocobalamin (Vit B12a)
-Binds cyanide forming cyanocobalamin with direct renal excretion.